Brain imaging in lung cancer patients without symptoms of brain metastases: a national survey of current practice in England.

AIM: To determine current practice regarding brain imaging for newly diagnosed lung cancer patients without symptoms of brain metastases. MATERIALS AND METHODS: A survey questionnaire was sent by e-mail to all the lung cancer lead clinicians in England currently on the National Cancer Intelligence Network database. The survey asked whether brain imaging was used in new lung cancer patients without symptoms or signs to suggest brain metastases; and if so, which patient subgroups were imaged according to cell type, stage of disease, and intention to treat, and which techniques were used to image these patients. Responses were received between February and May 2014. RESULTS: Fifty-nine of 154 centres replied to the survey (38%). Thirty of the 59 centres (51%) did not image the brain in these patients. Twenty-nine of the 59 (49%) centres imaged the brain in at least certain subgroups. Of those centres that did image the brain 21 (72%) used CT as the first-line imaging technique and six (20%) used MRI. Twenty-five of 59 (42%) centres stated that the 2011 NICE guidelines had led to a change in their practice. CONCLUSION: There is wide variation in practice regarding brain imaging in this patient group in England, with no brain imaging at all in approximately half of centres and a spectrum of imaging in the other half. When the brain is imaged, CT is the technique most commonly used. The 2011 NICE guidelines have led to some change in practice but not to national uniformity.

Alcohol affects emotion through cognition.

Determining how, cognition and emotion interact is pivotal to an understanding of human behavior and its disorders. Available data suggest that changes in emotional reactivity and behavior associated with drinking are intertwined with alcohol's effects on cognitive processing. In the study reported here, we demonstrated that alcohol dampens anticipatory fear and response inhibition in human participants not by directly suppressing subcortical emotion centers, as posited by traditional tension-reduction theories, but instead by impairing cognitive-processing capacity. During intoxication, reductions in fear response (assessed via startle potentiation) occurred only under dual-stimulus conditions, and coincided with reduced attentional processing of threat cues as evidenced by brain response (assessed via P3 event-related potentials). The results are consistent with higher cortical mediation of alcohol 's effects on fear, and illustrate more broadly how disruption of a cognitive process can lead to alterations in emotional reactivity and adaptive behavior.

A startle-probe methodology for investigating the effects of active avoidance on negative emotional reactivity.

This study introduces a new methodology for investigating the impact of active avoidance and behavioral control on defensive emotional reactivity using the startle reflex. A between-groups yoked design was devised that permitted manipulation of participants' perception of control over an aversive event (loud noise) while precisely controlling motor activity and noxious stimulation. Startle responses to tactile (airpuff) probes were compared during threat/performance trials and neutral trials. Results conclusively demonstrated cross-modal startle potentiation in the context of a continuous motor performance task. Also, consistent with prior research, heart rate increased with perceived control. However, behavioral control per se did not appear to mitigate defensive emotion as indexed by startle potentiation. These findings indicate that other parameters may mediate the efficacy of active coping in addition to control, and that the startle probe paradigm can provide a valuable tool for investigating these parameters in future research.

Alcohol and fear-potentiated startle: the role of competing cognitive demands in the stress-reducing effects of intoxication.

Effects of alcohol and cognitive demands on reactions to threat were examined using startle response potentiation to index negative emotion. Men and women received nonalcoholic or alcoholic beverages prior to a series of trial blocks, signaled by light cues indicating that shocks might be delivered ("threat" blocks) or that none would occur ("safe" blocks). Within half of the blocks, participants intermittently viewed pleasant photographic slides. Alcohol attenuated overall startle reactivity, but robust fear potentiation (larger startle magnitudes and shorter latencies during threat versus safe blocks) did not differ by beverage condition. Decomposition of the Beverage x Threat x Slide interaction revealed significant fear potentiation in all conditions, except the one in which alcohol was combined with slides. Thus, dampening of stress response by alcohol may depend on diminished ability to process competing cognitive demands.

Breastfeeding among low-income women with and without peer support.

This research examined the effect of peer support on breastfeeding duration and exclusivity (breastfeeding without supplements) in a population of low-income women during the first 3 months postpartum. Participants in the peer counselor group (n = 18) exhibited higher rates of exclusive breastfeeding across time than those without a counselor (n = 18), and more exclusive breastfeeding was associated with long duration overall. Mother's career plans had the greatest effect on duration of breastfeeding. Women who intended to return to work, attend school, or both breastfed 6 to 9 weeks less than participants who intended to stay home. Attendance at a breastfeeding class and knowing someone who had breastfed was significantly correlated with a longer duration of breastfeeding. Nutritionists from the Women, Infants and Children (WIC) Program were the primary source of breastfeeding information. Two main factors discouraged women from breastfeeding: returning to work, school, or both and the perception of a diminished milk supply. Greater emphasis should be placed on prenatal breastfeeding education for low-income women, and their mothers and grandmothers should be included. Peer support is one important component of social support in the area of breastfeeding that community health nurses (CHNs) can utilize. CHNs are in a unique position to assist working mothers, provide support, and develop educational programs to enhance breastfeeding success in this population.

Thin-section spiral volumetric CT for the assessment of lobar and segmental bronchial stenoses.

Thin-section volumetric computed tomography (CT) was used to examine the lobar and segmental bronchi of five patients who had stenoses of these airways diagnosed by previous bronchography and/or bronchoscopy. Four of 23 lobar bronchi and 42 of 72 segmental bronchi were judged to be stenotic by CT. Our findings in this small group suggest that thin-section volumetric CT is a promising non-invasive technique that is likely to prove useful in the assessment of such stenoses in the future.

Fast gradient echo magnetic resonance imaging of the normal diaphragm.

To determine the ability of fast gradient-recalled echo (GRE), breath-hold magnetic resonance imaging (MRI) to depict all regions of the diaphragm, 13 volunteers were scanned in coronal and sagittal planes. The central to anterior left hemidiaphragm and the posterior lumbar portions were each demonstrated in 12 subjects (92%). The crura were visible crossing anterior to the aorta in the sagittal plane in eight subjects (62%) and in the coronal plane in six subjects (46%). In the sagittal plane, the right crus was evident in eight subjects (62%). Muscular portions of the diaphragm in contact with the liver or body wall were less frequently discernible, and the central tendon could not be confidently resolved. Several artifacts occurred that interfered with visualization of the diaphragm. These observations indicate that many regions of the diaphragm can be seen with fast GRE, breath-hold MRI, but there are some limitations in depicting the diaphragm in its entirety.

Mediastinal lymph node enlargement and splenomegaly in primary hypogammaglobulinaemia.

The computed tomography (CT) scans of 37 patients with primary hypogammaglobulinaemia were reviewed to determine the frequency of enlarged mediastinal lymph nodes and splenomegaly in this group. None of the 10 X-linked Agammaglobulinaemia (XLA) patients had enlarged nodes and only one had splenomegaly. Eleven of the 27 Common Variable Immunodeficiency (CVID) group had enlarged nodes (41%) and 13 had splenomegaly (48%). There was no significant correlation between the presence of enlarged nodes and splenic enlargement. Twenty-two patients had bronchiectasis but the presence of bronchiectasis did not correlate with the presence of either splenomegaly or lymphadenopathy. Three to 6 years follow-up is available for 36 of the 37 patients and none of this group have developed lymphoma or other malignancy. Enlarged mediastinal nodes and/or splenomegaly are frequently found in patients with CVID and are usually due to a benign, non-neoplastic, process. Mediastinal lymph node enlargement is not a feature of XLA and splenomegaly is unusual in this condition.

Detection of pulmonary embolism in patients with unresolved clinical and scintigraphic diagnosis: helical CT versus angiography.

OBJECTIVE: This study was designed to prospectively compare helical CT with pulmonary angiography in the detection of pulmonary embolism in patients with an unresolved clinical and scintigraphic diagnosis. SUBJECTS AND METHODS: Twenty patients with an unresolved suspicion of pulmonary embolism were evaluated with contrast-enhanced helical CT and with selective pulmonary angiography. An average of 11 hr separated the two studies. The CT scans were obtained during one 24-sec or two 12-sec breath-holds. CT scans were interpreted without knowledge of the results of scintigraphy or angiography. Selective pulmonary angiograms were obtained with knowledge of the findings on the ventilation/perfusion scan only. The sensitivity and specificity of CT were compared with those of angiography for central vessels (segmental and larger) only and for all vessels. RESULTS: Eleven of the 20 patients had proved pulmonary embolism (seven in central vessels and four in subsegmental vessels only). When only central vessels were analyzed, CT sensitivity was 86%, specificity was 92%, and the likelihood ratio was 10.7. However, when subsegmental vessels were included, CT results were 63%, 89%, and 5.7, respectively. CONCLUSION: In our subset of patients, helical CT was only 63% sensitive. Subsegmental emboli are difficult to diagnose. Pulmonary angiography remains the study of choice. CT has a limited role in the evaluation of acute pulmonary embolism.

Mediastinal lymph node size in an Asian population.

There is a high incidence of respiratory tuberculosis in the British population of Indian subcontinent (Asian) ethnic origin. Granulomatous diseases can cause long term lymph node enlargement. Separate computed tomography (CT) criteria for normal nodal size could therefore be necessary when staging thoracic malignancy in Asian patients. The objective of this study was to measure mediastinal lymph node size in an Asian population, and to correlate nodal size with previous tuberculosis. Chest CT scans on all Asian patients over a 5 year period were reviewed and those with pulmonary disease, malignancy or grossly distorted anatomy were excluded. The study group consisted of 48 patients (26 male, 22 female) aged 10-75 years (mean 47 years). All nodes were measured and the site of those greater than 7 mm was recorded using the American Thoracic Society (ATS) lymph node map. 81.3% of patients had nodes less than or equal to 7 mm at all ATS stations, 10.4% had nodes of 8-10 mm and 8.3% had nodes greater than 10 mm. All nodes measuring more than 7 mm were in regions 4R, 10R and 7. Fourteen patients had signs of previous tuberculosis, and in this group 50% had nodes greater than 7 mm as compared with 6% in the group with no signs of previous tuberculosis (p < 0.001, X2 test). Despite these differences only four of the 48 patients (8.3%) had nodes greater than 10 mm, which is in keeping with other general population studies. Thus the generally accepted size criteria for mediastinal lymph node enlargement (greater than 10 mm) can reasonably be applied to all Asian patients when staging lymphoma or bronchogenic carcinoma.

Diaphragmatic motion: fast gradient-recalled-echo MR imaging in healthy subjects.

PURPOSE: To investigate the feasibility of imaging diaphragmatic motion with a fast gradient-recalled-echo (GRE) magnetic resonance (MR) pulse sequence. MATERIALS AND METHODS: Fast GRE pulse sequences in sagittal and coronal planes were used to acquire repeated, single-level, 1.2-second scans in 10 healthy volunteers during deliberately slowed, approximate-vital-capacity breathing. Motion was analyzed subjectively by viewing the image sequences as cine loops and quantitatively by measuring the displacement of different points on the diaphragm at a workstation. RESULTS: Temporal and spatial resolutions were adequate in all subjects. Absolute excursion of the domes was 4.4 cm on the right and 4.2 cm on the left. Analysis of diaphragmatic displacement at different locations revealed a gradient of excursion that increased from anterior to middle to posterior (P < .05-.001; paired t test). Excursion of the lateral aspects was greater than that of the medial aspect (P < .001). CONCLUSION: Fast GRE MR imaging can be reliably used to demonstrate diaphragmatic motion and may prove useful in the investigation of normal and abnormal respiratory mechanics.

Thoracostomy tubes after acute chest injury: relationship between location in a pleural fissure and function.

OBJECTIVE: The purpose of this study was to determine how often chest tubes placed for acute trauma lie within a pleural fissure and to determine whether an intrapleural location influences outcome. SUBJECTS AND METHODS: Fifty-eight consecutive thoracostomy patients who had 66 chest tubes were studied prospectively. Tube location was determined from frontal and lateral chest radiographs. Outcome measures recorded included the following: duration of thoracostomy drainage, quantity of pleural fluid drained, need for further tubes, length of hospital stay, appearance on last chest radiograph before discharge, and need for surgical intervention. RESULTS: Thirty-eight (58%) of the tubes were placed within a pulmonary fissure, 15 (23%) were posterior, nine (13%) were anterior, and four (6%) were in other locations. We found no significant difference in any of the outcome measures between tubes located in the fissure and other tubes. CONCLUSION: A large percentage of tubes placed for acute chest trauma lie within a pleural fissure. These tubes, however, appear to function as effectively as those located elsewhere in the pleural space.

Postcontrast CT in the diagnosis and assessment of response to thrombolysis in massive pulmonary embolism.

We present a case of massive acute pulmonary embolism where contrast enhanced helical CT was compared with standard angiography for diagnosis and for monitoring subsequent response to thrombolytic therapy. There was very close concordance of the findings on these modalities suggesting that contrast enhanced helical CT may be an easy and reliable alternative to standard angiography.

[Aortic traumatic lesion. Has tomodensitometry a role?]. / Lésion traumatique aortique. La tomodensitométrie a-t-elle un rôle?

The low positive yield from aortography in patients with suspected traumatic aortic rupture has prompted research into CT of the mediastinum as a screening investigation which could significantly reduce the number of negative angiograms performed. Much of the data published to date suggest a promising role for CT, but false negative scans have been reported and the precise false negative rate has yet to be determined. We propose an algorithm for the use of CT in suspected traumatic rupture but emphasise that continuous monitoring of outcomes and further large studies are required before CT can become an established screening technique.

Need for open access non-screening mammography in a hospital with a specialist breast clinic service.

OBJECTIVE: Assessment of open access non-screening mammography in a hospital with a breast clinic. DESIGN: Retrospective analysis of patients sent for first mammogram to our open access service by general practitioners and breast clinic in the year April 1989 to March 1990. SETTING: District general hospital serving 200,000 people before the introduction of breast screening. SUBJECTS: 361 symptomatic women referred directly by general practitioners and 226 women referred by the breast clinic for first, non-screening mammograms. MAIN OUTCOME MEASURES: Radiographic reports on all patients. Final diagnosis in patients reported as having possible or probable neoplasm. RESULTS: Of the women referred directly by general practitioners one (0.2%) was reported as showing probable malignancy (later histologically confirmed) and 15 (4%) as showing possible malignancy (on follow up none had proved malignancy). Of the women referred by the breast clinic 38 (17%) were reported as showing probable malignancy (all had confirmed carcinomas) and 35 (15%) as showing possible malignancy (19 (54%) had proved malignancy). 18 of the proved malignancies were in women under 50 years old, 26 were in women over 64 years, and 14 were in women of screening age. 54 (93%) of the 58 patients with proved breast cancer and an abnormal mammogram had a discrete breast lump. CONCLUSIONS: General practitioners accurately divided women into low and high risk groups, resulting in few abnormalities being detected in patients referred directly for mammography. This suggests that an open access non-screening mammography service for general practitioners is unnecessary in an area with a specialist breast clinic. The large proportion of cancers in women outside of screening age emphasises the need for such clinics.

Pneumoparotitis.

Pneumoparotitis is a rare cause of parotid enlargement. It is due to a reflux of air through Stensen's duct into the acini of the parotid gland with subsequent dilatation. We report a case which followed a long history of autoinflation of the middle ears by the Valsalva manoeuvre. The plain radiographic, sialographic and ultrasound findings are presented.

Bronchiectasis in hypogammaglobulinaemia--a computed tomography assessment.

To determine the pattern of bronchiectasis in hypogammaglobulinaemia we reviewed the CT scans of 38 hypogammaglobulinaemic patients. Twenty-two had bronchiectasis, seven had bronchial wall thickening without bronchiectasis and the remaining nine were normal. The middle lobe was the most common site of bronchiectatic involvement, followed by the lower lobes and the lingula. There were no cases of isolated upper lobe involvement. In patients who had bronchial wall thickening without bronchiectasis the middle lobe and lower lobes were again most commonly affected. It is postulated that in these hypogammaglobulinaemic patients bronchial wall thickening represents a stage of bronchial inflammation prior to the development of bronchiectasis. Patients with X-linked agammaglobulinaemia (XLA) develop bronchiectasis at a significantly earlier age than those with 'common variable' hypogammaglobulinaemia (CVH) (P = 0.02). No correlation was found between the serum levels of immunoglobulin classes at diagnosis and the subsequent development of bronchiectasis.